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          <h1 class="post-title" itemprop="name headline">聊聊高血压</h1>
        

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        <p>最近准备一个重要考试，好长时间没发文章了。我们口腔医生在日常接诊中经常会碰到高血压患者，查了一些资料，主要是中国的指南。分享给大家。</p>
<p>2012-2015年患病粗率：27.9%（标化率 23.2%）<br>18-24岁：4.0%<br>25-34岁：6.1%<br>35-44岁：15.0%<br>男高于女，北高于南。<br>危险因素：高钠、低钾饮食、超重和肥胖、过量饮酒（危险饮酒：男41-60g，女21-40g；有害饮酒：男60g以上，女40g以上）、长期精神紧张、其它（年龄、家族史、缺乏体力活动、糖尿病及血脂异常、大气污染）<br>诊断：未使用降压药，非同日3次测量诊室血压，收缩压（SBP）≥140mmHg和（或）舒张压(DBP)≥90mmHg。24小时动态血压标准， 24h平均≥130/80mmHg，白天≥135/85mmHg，夜间≥120/70mmHg。<br>分类<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/01.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/02.png"><br>治疗：根本目标是降低发生心脑肾及血管并发症和死亡的总危险。降压治疗的获益主要来自血压降低本身。在改善生活方式的基础上，应根据高血压患者的总体风险水平决定给予降压药物，同时干预可纠正的危险因素、靶器官损害和并存的临床疾病。在条件允许的情况下，应采取强化降压的治疗策略，以取得最大的心血管获益。降压目标：一般高血压患者应降至&lt;140/90mmHg；能耐受者和部分高位及以上的患者可进一步降至&lt;130/80mmHg。<br>降压药物治疗时机：取决于心血管风险评估水平，在改善生活方式的基础上，血压仍超过140/90mmHg和（或）目标水平的患者应给予药物治疗。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/03.png"><br>生活方式干预：①减少钠盐摄入，&lt;6g每日(2400mg/d)，增加钾摄入（富钾食物：新鲜蔬菜，水果，豆类。肾功能良好者可选择低钠富钾替代盐。）。②合理膳食，平衡膳食。（饮食以水果、蔬菜、低脂奶制品、富含食用纤维的全谷物、植物来源的蛋白质为主，减少饱和脂肪和胆固醇摄入。）③控制体重，BMI&lt;24，腰围：男性&lt;90cm，女性&lt;85cm。④彻底戒烟，避免被动吸烟。⑤不饮或限制饮酒。（每日酒精摄入量男性不超过25g，女性不超过15g，每周酒精摄入量男性不超过140g，女性不超过80g。白酒、葡萄酒、啤酒摄入量分别少于50ml，100ml，300ml）⑥增加运动，中等强度，每周4-7次，每次持续30-60分钟。⑦减轻精神压力，保持心理平衡。<br>降压药应用的基本原则：<br>①常用的五大类降压药物均可作为初始治疗用药，个体化治疗。<br>②根据血压水平和心血管风险选择初始单药或联合治疗。<br>③一般患者采用常规剂量，老年人及高龄老年人初始治疗时通常应采用较小的有效治疗剂量。根据需要，可考虑逐渐增加至足剂量。<br>④优先使用长效降压药，以有效控制24小时血压，更有效预防心脑血管并发症发生。<br>⑤对血压≥160/100mmHg的高危患者，或单药治疗未达标的高血压患者应进行联合降压治疗，包括自由联合或单片复方制剂。<br>⑥对血压≥140/90mmHg的患者，也可起始小剂量联合治疗。<br>降低血压是降压药物减少心脑血管并发症的最主要原因，药物之间的差别总体很小。<br>常用降压药物<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/04.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/05.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/06.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/07.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/08.png"><br>各种药物药理作用：<br>①CCB：阻断血管平滑肌细胞上的钙离子通道发挥扩张血管降低血压作用。常见不良反应包括反射性交感神经激活导致心跳加快、面部潮红、脚踝部水肿，牙龈增生等。心动过速与心力衰竭患者慎用。急性冠脉综合征患者一般不推荐用短效硝苯地平。非二氢吡啶类CCB常见不良反应包括抑制心脏收缩功能和传导功能，二度至三度房室阻滞；心力衰竭患者禁用。有时也会出现牙龈增生。<br>②ACEI：抑制血管紧张素转换酶，阻断肾素血管紧张素Ⅱ生成，抑制激肽酶的降解而发挥降压作用。降压作用明确，对糖脂代谢无不良影响。最常见不良反应为干咳，多见于用药初期，症状较轻者可坚持服药，不能耐受者可改用ARB。其他不良反应为低血压、皮疹，偶见血管神经性水肿及味觉障碍。长期应用可能导致血钾升高。禁忌症未双肾动脉狭窄、高钾血症及妊娠妇女。<br>③ARB：作用机制是阻断血管紧张素Ⅱ1型受体而发挥降压作用。尤其适用于伴左心室肥厚、心力衰竭、糖尿病肾病、冠心病、代谢综合征、微量白蛋白尿或蛋白尿患者以及不能耐受ACEI患者，并可预防房颤。不良反应少见，偶有腹泻、长期应用可升高血钾。双肾动脉狭窄、妊娠妇女、高钾血症者禁用。<br>④利尿剂：主要通过利钠排尿、降低容量负荷而发挥降压作用。小剂量噻嗪类利尿剂（如氢氯噻嗪6.25-25mg）对代谢影响很小，与其它降压药（尤其ACEI或ARB）合用可显著增加后者的降压作用。尤适用于老年高血压、单纯收缩期高血压或伴心力衰竭者，也是难治性高血压的基础药物之一。不良反应与剂量密切相关，故通常应采用小剂量。噻嗪类利尿剂可引起低血钾。痛风者禁用。对高尿酸血症以及明显肾功能不全者慎用。如需使用应用襻利尿剂，如呋塞米等。保钾类利尿剂在利钠排尿的同时不增加钾的排出，与其它具有保钾作用的降压药如ACEI或ARB合用时需注意发生高钾血症的危险。螺内酯长期应用可能导致男性乳房发育等不良反应。<br>⑤β受体阻滞剂：主要通过抑制过度激活的交感神经、抑制心肌收缩力、减慢心率发挥降压作用。高选择性β1受体阻滞剂对β1受体有较高选择性，因阻断β2受体而产生的不良反应较少。尤其适用于伴快速性心律失常、冠心病、慢性心力衰竭、交感神经活性增高以及高动力状态的高血压患者。常见不良反应有疲乏、肢体冷感、激动不安、胃肠不适等，还可能影响糖、脂代谢。二、三度房室传导阻滞、哮喘患者禁用。慢性阻塞性肺病、运动员、周围血管病或糖耐量异常者慎用。长期应用者突然停药可发生反跳现象。<br>⑥α受体阻滞剂：不作为高血压治疗的首选药，适用于高血压伴前列腺增生患者，也用于难治性高血压患者的治疗。体位性低血压者禁用，心力衰竭者慎用。<br>⑦肾素抑制剂：较新的药，还需大规模RCT评估。<br>临床选择：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/09.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/10.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0226-HBP/11.png"></p>
<p>降压药物药理学<br>分类<br>一、利尿降压药<br>1.噻嗪类利尿药(氢氯噻嗪，氯噻酮等)<br>2.袢利尿药(呋噻米，依他尼酸)<br>3.保钾利尿药(螺内酯，氨苯蝶啶)<br>二、钙通道阻滞药(硝苯地平，维拉帕米，地尔硫卓)<br>三、肾素-血管紧张素系统抑制药<br>1.血管紧张素Ⅰ转化酶抑制剂(卡托普利，依那普利，雷米普利)<br>2.血管紧张素Ⅱ受体阻断药(氯沙坦，替米沙坦，缬沙坦)<br>3.肾素抑制药(雷米克林)<br>四、交感神经抑制药<br>1.中枢性降压药(甲基多巴，可乐定)<br>2.神经节阻断药(樟磺咪芬)<br>3.去甲肾上腺素能神经末梢阻滞药(利血平，胍乙啶)<br>4.肾上腺素受体阻断药<br>①β受体阻断药(普萘洛尔，美托洛尔)<br>②α受体阻断药(哌唑嗪)<br>③α及β受体阻断药(拉贝洛尔，卡维地洛)<br>五、血管扩张药<br>1.直接舒张血管平滑肌药(肼屈嗪，硝普钠)<br>2.钾通道开放药(二氮嗪，米诺地尔)</p>
<p>参考文献：<br>1.《中国高血压防治指南》修订委员会. 中国高血压防治指南2018年修订版.<br>2.杨世杰 主编.药理学.人民卫生出版社,2005年8月第一版.</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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